NSA Good Faith Estimate Client Signature Page

Client Name:

Client Date of Birth:

My signature below indicates that I have received the No Surprise Act Standard
Notice and the “Your Rights and Protections Against Surprise Medical Bills” Notice
and that my provider, Dr. Quincy Warner, of BCC, has gone over my No Surprise
Act Good Faith Estimate with me and any questions or concerns have been
addressed.

I voluntarily choose and ask that my typed name on the signature line(s) on
this document represent my legal electronic signature.

Client Signature:

Date of Signature:

Print Name of Client’s guardian/authorized representative:

Signature of Client’s guardian/authorized representative:

Date of Signature:

Guardian’s Relationship to Client: